Download pdf - CBFisher ABCT ClinEthics 1 30 15REV

THE CENTER FOR ETHICS EDUCATION CELIA B. FISHER, PH.D., DIRECTOR

Doing Good Well: The Ethical Conduct of Clinical Psychology

Celia B. Fisher, Ph.D. Marie Ward Doty University Chair & Professor of Psychology Director, Center for Ethics Educa<on Director, HIV & Drug Abuse Preven<on Research Ethics Training Ins<tute [email protected] www.fordham.edu/ethics



Disclosures

I have no conflicts of interest to disclose and have not received any funding from any commercial en66es that may be men6oned or discussed in this presenta6on.

All informa6on and opinions shared are those of the presenter only.

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Major Topics

•  Applying the APA Ethics Code to everyday clinical prac<ce

•  Informed consent for diverse treatment modali<es and popula<ons

•  Client sensi<ve confiden<ality and disclosure policies

•  Avoiding harm and maintaining boundaries

•  Respec<ng Client Diversity 3


Applying the APA Ethics Code APA 2010

Aspira<onal Principles

•  Beneficence/Nonmaleficence •  Fidelity/Responsibility •  Integrity •  Jus<ce •  Respect

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Applying the APA Ethics Code

Enforceable Standards

•  6 General/4 Area Specific •  Behavioral Rules provided Due No<ce •  Use of modifiers: “Feasible” “Reasonable” •  APA specialty guidelines

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THE CENTER FOR ETHICS EDUCATION

CELIA B. FISHER, PH.D., DIRECTOR

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INFORMED CONSENT •  Informed consent basics

•  Health literacy and medical mistrust

•  Suicidal pa<ents

•  Children/adolescents

•  Family/couples therapy

•  Group therapy

•  Internet policies


Informed Consent: Building the TherapeuKc Alliance

Standards 3.05, 10.01

•  Client-‐centered language

•  Opportunity to ask ques<ons and receive answers

•  Limits of confiden<ality: What will be shared with insurers

•  Risks and alterna<ves for new or emerging treatments

•  As early as feasible

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Need to Know

HIPAA No<ce of Privacy Prac<ces must be a separate document

Ins<tu<onal consent by intake staff does not subs<tute for therapist informed consent

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Nature and AnKcipated Course of Therapy

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•  Dura<on of sessions

•  Treatment modality

•  Number of sessions given current knowledge of presen<ng problem

•  Re-‐consent when ini<al goals are met or modified based on revised diagnosis

•  Do not assume client is familiar with psychotherapy!




Fees Standard 6.04; 4:04

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•  Session costs and annual fee increases

•  Payment schedule and type of payment accepted

•  Health care plan: Limita<ons on sessions

•  Missed appointments

•  Late payment, collec<on agencies

“minimum necessary” Standard 4.04 Inclusion in No<ce of Privacy Prac<ces




Need to Know: When Insurers Refuse Extended Coverage

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Did you take reasonable steps to:

•  Learn about and communicate to client about an<cipated number of covered sessions at outset?

•  Communicate with insurer when need for con<nuing treatment became apparent?

•  Be prepared to handle client’s response to termina<on of coverage?


Health Literacy & Medical Mistrust

WHO

•  Recently immigrated

•  Non-‐English language communi<es

•  Lack of health literacy opportuni<es

•  Those experiencing health care dispari<es

CONSENT CHALLENGE

•  Medical Mistrust

•  Lack of familiarity with treatment goals, procedures and terminology

•  Lack of familiarity with terms and concepts of voluntary choice and other client rights

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Health Literacy & Medical Mistrust

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INFORMED CONSENT ETHICAL PRACTICE •  Include educa<onal components during informed consent

•  Be aware that language preferences do not always indicate language proficiency




Use of Interpreters Standard 2.05

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Select trained interpreters and Ini<ate pre-‐and post session training to ensure that the interpreter has competencies to: •  Interpret consent relevant concepts

•  Cultural meanings not just word for word transla<ons

•  Iden<fy when clients are confused or concerned about consent relevant informa<on

•  Facilitate client-‐psychologist discussion of ques<ons

•  Refrain from reframing informa<on in a misguided but well-‐inten<oned desire to avoid culture embarrassment




Informed Consent with Suicidal Clients Rudd, Joiner et al (2009)

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Frank discussion about suicide risk during informed consent:

•  Assists clients (& families) in understanding suicide risk during treatment

•  Establishes prac<<oner/client/family shared responsibility to reduce its likelihood

•  Helps clarify importance of treatment compliance & crises management

•  Provides opportunity to emphasize need for effec<ve self-‐management during out-‐pa<ent care

•  Helps psychologist iden<fy & target skill deficits that limit client willingness/ability to access emergency services




Child/Adolescent Therapy

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•  State laws regarding guardian permission/waiver

•  HIPAA rules on “personal representa<ve”

•  Developmental data on children’s understanding of therapy, mental health disorders, and treatment rights (Standard 2.04)

•  Scien<fic and clinical knowledge on rela<onship between diagnoses and cogni<ve and emo<onal capacity to consent (Standard 2.04)

•  Individual evalua<on of client’s apprecia<on of mental health needs and history of health care decision-‐making

•  NEVER ASK A CHILD TO CONSENT IF THEIR REFUSAL WILL NOT BE RESPECTED




Family and Couples Therapy Standard 10.02

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•  Which individuals are clients

•  Individual/conjoint sessions

•  Correct misimpressions in expecta<ons on treatment goals

•  Secret sharing policies

•  State laws governing privilege in case of child custody, divorce or other legal proceedings

•  Mandated repor<ng requirements

•  Be aware of signs of child abuse, elder abuse, and IPV (see relevant APA Guidelines in references)




Group Therapy Standard 10.03

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•  Group member responsibility: Turn taking, prohibi<ons against socializing outside sessions

•  Confiden<ality: Therapist and member obliga<ons

•  Clients responsibili<es in acceptance of diverse opinions, abusive language, coercive or aggressive behaviors, member scapegoa<ng

•  Termina<on policies and voluntary withdrawal




Concurrent Single/Group Therapy Brabender & Fallon, 2009

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•  Why clinically indicated (Standard 3.05, 3.06, 3.08)

•  Voluntary or required at outset of treatment

•  Concerns about cost and <me

•  Differences in exclusivity of therapist’s aien<on vs aien<on to group dynamics

•  Confiden<ality across modali<es




Informed Consent: Electronic CommunicaKon Policy

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•  INTERNET SEARCH POLICY: For emergency contact, corroborate client clinically relevant statements

•  SOCIAL MEDIA POLICY: Friending, fanning; following twiier or blog posts; cancelling uninten<onal online rela<onship

•  EMAIL/TEXTING POLICIES: Billing, appointments, administra<ve—policy on responding to clinical ques<ons

•  PROFESSIONAL WEBSITE POLICY: be mindful of client access to personal informa<on on Internet




E-‐Therapy

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•  Cyber security a 2-‐way street

•  Limits of insurance coverage-‐-‐Submiied claims must clearly iden<fy services as electronic with specific IDs

•  Ini<al and con<nuing verifica<on of iden<ty, age, state, contact informa<on, support contacts

•  Know state laws on e-‐therapy involving minors




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CONFIDENTIALITY •  General requirements

•  Responding to client request for disclosure

•  Implica<ons of HIPAA

•  Disclosure policies: Harm to self or others

•  Involvement of parents in child/adolescent treatment




ConfidenKality: General Requirements Standards 4.01, 4.02

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•  Password protect all records

•  Ins<tu<onal Cyber security

•  Keep progress notes separate from Protected Health Informa<on (PHI: HIPAA)

•  When electronically transmiong PHI encrypt when appropriate and ensure receiver is HIPAA compliant

•  Avoid when possible and develop confiden<ality protec<on procedures for telephone or other electronic messages




Need to Know: Under HIPAA

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Insurers do not have access to psychotherapy notes

Insurers should not be given access to names of clients not covered by insurer




Client Request for Disclosure of ConfidenKal InformaKon

Standard 4.05 & HIPAA

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Obtain signed HIPAA authoriza<on specifying: •  Recipient

•  Time limita<ons

•  Nature of informa<on disclosed

Psychologists may decline request if: •  They believe it will cause harm client, but…

•  HIPAA defines harm as physical endangerment or life-‐threatening AND permits appeal by licensed health professional




Need to Know

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•  Clients do not have access to psychotherapy/process notes as long as they are filed separately from PHI

•  When working for or receiving informa<on from an ins<tu<on or aiorney confirm appropriate consent/authoriza<on




Disclosures w/out Client Consent: Duty to Protect

Standard 4.05b

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•  Special Rela<onship

•  Established scien<fic or clinical basis for predic<ng violence and immediacy of threat;

•  Iden<fiable vic<m*

•  *Some courts have broadened requirement to iden<fiable popula<on of vic<ms




Disclosures: Suicidal Intent Jobes, Rudd, Overholser & Joiner, 2008

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COMPETENCIES

•  Training to recognize, manage and treat suicidality

•  Prior iden<fica<on of social support and community resources

•  Knowledge of legal principles and ins<tu<onal policies regarding voluntary or involuntary commitment




Disclosures: Suicidal Intent

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PROCEDURES

•  Evaluate level of risk

•  Draw on consulta<ve rela<onships with other professionals

•  Evaluate client’s support systems and ability to access emergency services

•  Involve client to the extent possible in disclosure procedure




Disclosure: Nonsuicidal Self-‐Injury Andover et al., 2010; Lieberman et al., 2008; Nock e al., 2006; Walsh, 2008

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•  Dis<nguish NSSI from suicidal behavior (e.g. cuong on extremi<es)

•  Recognize NSSI and suicidality can co-‐occur

•  Be familiar with gender differences in age of onset, degree of medical injury and NSSI methods

•  Be able to dis<nguish peer (body piercing) vs. pathology related self-‐injury (face, eyes, genitals)

•  Recognize when NSSI requires medical aien<on and know in advance local emergency services

•  When disclosing self-‐injury to parents, help dis<nguish NSSI from suicidality as well as possibility of future suicidal behaviors




ConfidenKality & Disclosure in Child/Adolescent Treatment

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1. The Consent Conference

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•  Establish a trus<ng rela<onship with child and parent(s)

•  Describe ethical and legal responsibili<es

•  Discuss developmentally appropriate confiden<ality and informa<on sharing

•  Obtain feedback

•  Establish confiden<ality policy consistent with professional standards, child’s clinical needs and cultural and familial context




2. Parental Requests for InformaKon

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•  Empathic and respecrul listening—assume genuine parental concern

•  Avoid turning request into power struggle

•  Guard against taking on parental counseling role

•  Help parents reframe confiden<ality: Child’s developing autonomy; Maintaining therapeu<c trust

•  Consider clinically appropriate child/parent sharing processes




3. Determine if Disclosure May be Warranted

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•  Confirm child is actually engaging in risk behavior

•  Is incident isolated? A con<nuing paiern? Escala<ng?

•  Assess child’s ability to terminate risk behaviors

•  Conduct appropriate risk reduc<on interven<ons; monitor behavior

•  Weigh therapeu<c, social, health, and legal consequences

•  An<cipate parents’ response to disclosure




4. Work with Client to Disclose

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•  Evaluate willingness of child to disclose to parents

•  Avoid entering into a clinically contraindicated “secrecy pact”

•  Be wary of assump<ons regarding client’s desire for confiden<ality

•  Prepare client for disclosure—respond to feelings, but do not avoid focus on disclosure process

•  Go over steps to be taken




5. Disclosing to Parent

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•  Involve child as much as possible

•  Frame within the context of ongoing treatment

•  Focus on posi<ve ac<ons child and parent can take

•  Provide appropriate referrals

•  Schedule follow-‐up mee<ngs with parents and client to monitor reac<ons and provide addi<onal guidance




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HUMAN RELATIONS •  Setting boundaries

•  Nonsexual physical contact with clients

•  Referrals from clients

•  Avoiding Harm: Exposure & Aversion therapies

•  Avoiding Harm: Psychotherapy

•  Terminating Therapy




Sefng Appropriate Boundaries Standards 3.05, 3.06, 3.08

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Boundaries protect against a blurring of personal and professional domains that could:

•  Impair the psychologist’s objec<vity, competence, or effec<veness to deliver services

•  Jeopardize clients’ confidence that psychologists will act in their best interests.

•  Risks client exploita<on or harm




Nonsexual Physical Contact

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•  Is physical contact consistent with treatment goals?

•  Will contact strengthen or jeopardize future treatment

•  How will client perceive contact?

•  Does contact serve needs of psychologist?

•  Is contact a subs<tute for more professionally appropriate behavior?

•  Is contact part of a con<nuing paiern of behavior that may reflect psychologist’s personal problems or conflicts?




Referrals from Clients Standard 3.05; Shapiro & Ginsberg, 2003

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EVALUATE

•  Does client’s mental health or mo<ve to refer suggest acceptance would be clinically contraindicated?

•  Is a former referring client likely to need the psychologist’s services in the future?

•  Can referral impair the psychologist’s objec<vity? Treatment effec<veness?

•  Does the psychologist’s current financial situa<on risk client exploita<on?

•  Has psychologist explicitly or implicitly encouraged referrals?




Referrals from Clients Standards 3.05

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PRECAUTIONS

•  Consider including a non-‐referral policy during informed consent

•  Provide professional referral in case of emergency

UNAVOIDABLE MULTIPLE RELATIONSHIPS: REFERRALS IN UNDER-‐SERVED POPULATIONS •  Consult with colleagues to ensure objec<vity

•  Take extra steps to protect confiden<ality

•  Engage clients in discussion of ethical challenges and steps psychologist will take to mi<gate risk

•  Encourage clients to alert psychologist to instances that might jeopardize his/her effec<veness




Avoiding Harm: Exposure & Aversion Therapies

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•  Is there evidence of treatment effec<veness for individuals similar to client in diagnosis, age, physical health, gender, culture?

•  Have empirically/clinically validated alterna<ve treatments been considered?

•  Has the nature of the treatment and an<cipated emo<onal/physical responses been adequately explained during ini<al informed consent and at the beginning of each subsequent treatment?

•  Is there a well-‐developed monitoring plan to: Minimize anxiety, avoid precipitous termina<on or ineffec<ve con<nua<on of treatment?




Can Behavioral and CogniKve Therapy Cause Harm?

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•  Treatments powerful enough to change cogni<on and behavior have the poten<al for iatrogenic effects

•  Fluctua<on of nega<ve symptoms and mental health needs are a natural course of evidence-‐based therapy

•  Harmful psychotherapies produce outcomes worse than what would have occurred without treatment (Dimidjian & Hollon, 2010)




Avoiding Psychotherapy Harms Barlow, 2010; Beutler et al, 2006; Castonguay et al, 2010; Lilienfeld, 2007

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•  Obtain training in flexible use of interven<ons

•  Avoid premature clinical interpreta<ons and over/under diagnosis

•  Determine whether client characteris<cs and treatment seong match those reported for specific EBP

•  Monitor change sugges<ng deteriora<on or lack of improvement

•  Con<nuously evaluate what works or interferes with posi<ve change

•  Aiend to and use client disclosures of frustra<on with treatment to evaluate and modify diagnosis, adjust treatment, and strengthen therapeu<c alliance




TerminaKng Therapy Standard 10.10

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WHEN •  Client pa<ent no longer needs service, not likely to benefit,

or is being harmed

•  Psychologist is threatened or endangered by client or person w/ whom the client has a rela<onship

HOW •  Conduct pre-‐termina<on counseling and suggest alterna<ve

services

•  Avoid persistence in contac<ng client who abruptly drops out of treatment




What is Abandonment?

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When client in imminent need of treatment is harmed by termina<on of services in the

absence of a clinically and ethically appropriate process (Younggren et al, 2011).




Avoiding Abandonment

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•  Develop termina<on plan at outset of treatment and discuss during IC along with nature and an<cipated course of therapy

•  Develop well conceptualized ra<onale for termina<on based on clinical, rela<onal, and situa<onal factors

•  Consult with client as early as feasible

•  Construct termina<on <meline and be responsive to client reac<on

•  Provide appropriate referrals if appropriate




NEED TO KNOW: AVOIDING ABANDONMENT

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•  Avoid unnecessary follow-‐up

•  Create record document key components of termina<on ra<onale and process




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Ethical Competence with Diverse PopulaKons

•  Ethical pluralism

•  Goodness-of-Fit Ethics

•  Diagnostic pluralism

•  Religion & spirituality in therapy




Competence

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Competence is the lynchpin of the discipline enabling psychologists to fulfill all other ethical

obliga<ons.




Competence & Ethical Pluralism Standard 2.01b

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•  Psychologists draw on established scien<fic and professional knowledge

•  To appropriately iden<fy factors associated with age, gender, gender iden<ty, race, ethnicity, culture, na<onal origin, religion, sexual orienta<on, disability, language, or socioeconomic status

•  Essen<al for effec<ve services




Goodness-‐of-‐Fit Ethics Fisher, 2003; 2013; 2014; Fisher & Ragsdale, 2006; Masty & Fisher, 2008

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•  What life circumstances render client more suscep<ble to the benefits or risks of the intended psychological assessment or treatment?

•  Are there aspects of the treatment or seong that are “misfiied” to client competencies, values, fears and hopes?

•  Does client have different concep<ons of treatment goals?

•  How can psychologist engage client in mutually respecrul dialogue to illuminate the lens through which each view the psychologist’s work?

•  How can psychologists draw on such dialogue to best harmonize their procedures to reflect the values and merit the trust of those they serve?




DiagnosKc Pluralism Korchin (1980, p. 264)

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“Pathology can be said to exist if a person:

•  Lacks voluntary control, ego strength, flexibility, and adaptability

•  Has only a weak sense of personal iden<ty

•  Feels driven by powerful and painful impulses and nega<ve affects

•  At the extreme, reveals disturbances of basic psychological func<ons (percep<on, learning, memory)…”




Avoiding Misdiagnosis Standard 2.04, 9.02

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•  Have EBP or DSM criteria has been validated on client popula<on?

•  Have compara<ve or deficit approaches led to inappropriate or overuse of certain diagnoses?

•  Are posi<ve mental health criteria based on majority group aotudes or behaviors?

•  Can I recognize the meaning func<on of par<cular behaviors/symptoms within the client’s par<cular cultural context?

•  How does the meaning of mental illness in the client’s life affect his/her mo<va<on and perseverance to sustain treatment?




PopulaKon SensiKvity vs. Stereotype

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•  Grouping clients into social categories that may not reflect how they see themselves

•  Over-‐ or under-‐es<ma<ng the role of cultural, gender, and other characteris<cs on the presen<ng problem?

•  Failing to recognize the fluid, evolving and mul<faceted nature of iden<ty

•  Precipitously separa<ng medical condi<ons from psychosocial and physiological and cumula<ve effects of discrimina<on




Religion and Spirituality in Therapy Bartoli, 2007; Fisher, 2013; Plante, 2007

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•  Understand how religion presents itself in mental health and psychopathology

•  Be able to iden<fy when a mental health problem is related to religious beliefs

•  Do not confuse religious values with mental health problems

•  Become familiar with techniques to assess and treat clinically relevant religious/spiritual beliefs and emo<onal reac<ons

•  Obtain knowledge of EBP on the use of religious imagery, prayer, or other religious techniques

•  Be familiar with appropriate role of tradi<onal medicines, clergy and cultural healers as conjunc<ve services




Need to Know

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•  Shared faith beliefs do not equal competence to provide religion sensi<ve psychotherapy

•  When appropriate discuss your approach to the role of religion in treatment during informed consent

•  Be aware of personal religious bias that may interfere with your objec<vity

•  Know boundaries between discussing treatment relevant responses to religious doctrine vs. religious counseling or imposing religious values




Religion and Therapy with LGBTQ Clients Magaldi-‐Dopman & Park-‐Taylor, 2010; Maihews et al., 2012; Sherry, 2010

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Obtain training in therapeuKc techniques to effecKvely address: •  Religious beliefs that may lead to higher levels of shame, guilt, and

internalized homophobia

•  Emo<ons associated with loss, grief, anger, reconcilia<on, or change in religious or spiritual iden<ty

•  Skills clients may need to separate spirituality from religion and to explore diversity of opinion within their faith community

•  The liabili<es and benefits of coming out to family members and others who endorse LGBTQ religious biases




NEED TO KNOW: RELIGION AND THERAPY WITH LGBTQ CLIENTS

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•  Rejec<on by one’s religious ins<tu<on does not mean LGBTQ clients are not deeply religious, spiritual or seeking to be!




Doing Good Well

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•  Psychologists are not technocrats working their way through a maze of ethical rules

•  The APA Code provides aspira<ons and general rules of conduct that must be interpreted and applied to the unique roles and rela<onships of clinical prac<ce

•  Good and justly implemented professional prac<ce relies on a concep<on of psychologists as ac<ve moral agents commiied to doing what is right because it is right.


QuesKons/further discussion

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References

•  Fisher, C. B. (2013). Decoding the ethics code: A prac6cal guide for psychologists. Thousand Oaks, CA: Sage Publica<ons.

•  American Psychological Associa<on (2010). Ethical principles of psychologists and code of conduct. hBp://www.apa.org/ethics/code/index.aspx

•  APA (1994). Guidelines for child custody evalua<ons in divorce proceedings. American Psychologist, 49, 677-‐680.

•  APA (1999). Guidelines for psychological evalua<ons in child protec<on maiers. American Psychologist, 54, 586-‐93

•  APA (2000). Guidelines for psychotherapy with lesbian, gay & bisexual clients. American Psychologist, 55, 1440-‐1451.

•  APA (2003). Guidelines on mul<cultural educa<on, training, research, prac<ce, and organiza<onal change for psychologists. American Psychologist, 58, 377-‐402.

•  APA (2004). Guidelines for Psychological Prac<ce with Older Adults. American Psychologist, 59, 236-‐260.

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References

•  APA (2007) Guidelines for Psychological Prac<ce With Girls and Women. American Psychologist, 62. 949-‐979.

•  Andover, M.S., Primack, J.M., Gibb, B.E., & Pepper, C.M. (2010). An examina<on of non-‐suicidal self-‐injury in men: Do men differ from women in basic NSSI characteris<cs? Archives of Suicide Research, 14(1), 79-‐88.

•  Barlow, D.H. (2010). Nega<ve effects from psychological treatments: A perspec<ve. American Psychologist, 65(1), 13-‐20.

•  Bartoli, E. (2007). Religious and spiritual issues in psychotherapy prac<ce: Training the trainer. Psychotherapy: Theory, Research, Prac6ce, Training, 44, 54-‐65.

•  Beutler, L. E., Blai, S.J., Alimohamed, S., Levy, K.N., & Angtuaco, L. (2006). Par<cipant factors in trea<ng dysphoric disorders. In L.G. Castonguay & L.E. Beutler (Eds.), Principles of therapeu6c change that work (pp. 13-‐63). New York, NY: Oxford University Press.

•  Brabender, V, & Fallon, A. (2009). Group development in prac6ce: Guidance for clinicians and researchers on stages and dynamics of change. Washington, D.C.: American Psychological Associa<on.

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References

•  Castonguay, L.G., Boswell, J.F., Constan<no, M.J., Goldfried, M.R., & Hill, C.E. (2010). Training implica<ons of harmful effects of psychological treatments. American Psychologist, 65(1), 34-‐49.

•  Fisher, C. B. (2003). A goodness-‐of-‐fit ethic for informed consent to research involving persons with mental retarda<on and developmental disabili<es. Mental Retarda6on and Developmental Disabili6es Research Reviews, 9, 27–31. PMID: 12587135.

•  Fisher, C. B. (2014). Mul<cultural Ethics in Professional Psychology Prac<ce, Consul<ng, and Training. In Frederick T.L. Leong (Ed.), APA Handbook of Mul6cultural Psychology. Vol. 2. (pp. 35-‐57). Washington, D.C.: APA Books.

•  Fisher, C. B., & Ragsdale, K. (2006). A goodness-‐of-‐fit ethics for mul<cultural research. In J. Trimble and C. B. Fisher (Eds.), The handbook of ethical research with ethnocultural popula6ons and communi6es (pp. 3–26). Thousand Oaks, CA: Sage.

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References

•  Jobes, D.A., Rudd, M., Overholser, J.C., & Joiner, T.E. (2008). Ethical and competent care of suicidal pa<ents: Contemporary challenges, new developments, and considera<ons for clinical prac<ce. Professional Psychology: Research and Prac6ces, 39(4), 405-‐413.

•  Korchin, S. J. (1980). Clinical psychology and minority problems. American Psychologist, 35, 262-‐269.

•  Lieberman, R., Toste, J.R., & Heath, N.L. (2008). Preven<on and interven<on in the schools. In M.K. Nixon & N. Heath (Eds.), Self injury in youth: The essen6al guide to assessment and interven6on. New York, NY: Routledge.

•  Lilienfeld, S.O. (2007). Psychology treatments that cause harm. Perspec6ves on Psychological Science, 2, 53-‐70.

•  Magaldi-‐Dopman, D. & Park-‐Taylor, J. (2010). Sacred adolescence: Prac<cal sugges<ons for psychologists working with adolescents' religious and spiritual iden<ty. Professional Psychology Research and Prac6ce, 41(5):382-‐390.

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References

•  Masty, J., & Fisher, C. B. (2008). A goodness of fit approach to parent permission and child assent pediatric interven<on research. Ethics & Behavior, 13, 139–160.

•  Maihews, Cynthia H.; Salazar, Carmen F. (2012). An integra<ve, empowerment model for helping lesbian gay & Bisexual youth nego<ate the coming=out process. Journal of LGBT Issues in Counseling. 2012, Vol. 6 Issue 2, p96-‐117.

•  Nock, M.K., Joiner, T.E., Gordon, K.H., Lloyd-‐Richardson, E., & Prinstein, M.J. (2006). Nonsuicidal self-‐injury among adolescents: Diagnos<c correla<ons and rela<on to suicide aiempts. Psychiatry Research, 144(1), 165-‐172.

•  Plante, T.G. (2007). Integra<ng spirituality and psychotherapy: Ethical issues and principles to consider. Journal of Clinical Psychology, 63, 891-‐902.

•  Rudd, M.D., Joiner, T., Brown, G.K., Cukowicz, K., Jobes, D.A., Silverman, M., & Cordero, L. (2009). Informed consent with suicidal pa<ents: Rethinking risk in (and out of) treatment. Psychotherapy 46(4), 459-‐468.

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References

•  Shapiro, E. L. & Ginzberg, R. (2003). To accept or not to accept: Referrals and the maintenance of boundaries. Professional Psychology: Research & Prac6ce, 34, 258-‐263.

•  Sherry, Alissa; Adelman, Andrew; Whilde, Margaret R. (2010). Quick, Daniel. Compe<ng selves: Nego<a<ng the intersec<on of spiritual and sexual iden<<es. Professional Psychology: Research & Prac<ce. Apr2010, Vol. 41 Issue 2, p112-‐119.

•  Walsh, B. (2008). Strategies for responding to self injury: When does the duty to protect apply? In J.L. Werth, E.R. Welfel, & G.A.H. Benjamin (Eds.), The duty to protect: Ethical, legal and professional considera6ons for mental health professionals (pp. 181-‐193). Washington, D.C.: American Psychological Associa<on.

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